An interesting discourse, this! Katz(1) says (speaking, presumably, to physicians) that 'you already think as a clinical epidemiologist' - while others claim that the 'mindlines' of clinical decision making are such that asking clinicians to switch to evidence-based patterns is unrealistic, a lost cause. Which is it? - or does this perspective mirror the theory/practice divide embodied by the debates over EBM?
What Katz says makes sense to me: I believe he is working to effect a switch in resource selection from internal to external, from instinctual to awareness (not necessarily exclusion) of bias. He claims that clinicians instinctively employ probability, using contextual awareness as an example. Working at a pediatric clinic, one makes certain assumptions about the population that figure into diagnostic processes: certain illnesses far more common to the elderly are almost automatically excluded from consideration. When examining a male, pregnancy is not a consideration.
In contrast, Gabbay & le May(2) argue that EBM does not reflect the needs or practices of physicians because they find near-complete satisfaction in their use of local expertise, more often relying upon that authority, seldom venturing beyond it. Wenger(3) agrees, saying that the “social and contextual nature” of knowledge, including local authority and political realities is not acknowledged by EBM (making the initiative inadequate to answer the needs of clinicians).
So, which is it? Are the two incommensurate, hence proving the claim of Sackett, et al. that EBM really IS a paradigm shift?
More later on this, I am sure.
1. Katz, DL. Clinical Epidemiology & Evidence-based Medicine: Fundamental Principles of Clinical Reasoning & Research. Thousand Oaks, CA: Sage, 2001.
This is a very readable book, by the way. Highly recommended for non physicians who'd like to understand more about clinical decision making (from this perspective).
2. Gabbay, J., & le May, A. (2004). Evidence based guidelines or collectively constructed "mindlines?" An ethnographic study of knowledge management in primary care. BMJ (Clinical Research Ed.), 329(7473), 1013.
3. Wenger, E. Communities of Practice: Learning, Meaning & Identity. Campbridge: Campbridge University Press, 1998.